Jonathan Zuckerman MD PhD

these are the areas I am referring to in the EM in one image. Not super specific, but could be the correlate for your IF staining.

or perhaps secondary overload injury from an original membranous nephropathy that has long resolved with just some IC staining. This is the best way I can put this together, but just my opinion. I agree this is not a typical case.

Given the GBM thickening and maladpative glomerular injury(hypertrophy), the IC staining may be incidental at this time and the patient's dx is mostly overload injury. Is the patient obese, have diabetes, HTN, smoking, MPN, low bithweight, etc.?

despite being much weak in reality. The GBM in the EM images do seem to show some undulation of the subepithelial surface which may be a subtle clue to some small mostly resorbed subepithelial deposits. So we may be seeing minimal residual subepithelial deposits from prior disease.

GBMs looks thick, you also mention glomerular hypertrophy. Wonder if some of the staining you see in the capillary loops is just "pseudolinear" IgG as we see in diabetic glomerulopathy and other metabolic dx associated glomerulopathy. Perhaps the small granular deposits are being enhanced here.

Can you post some of the EM images. Did you have conventional EM not just re-processing on the frozen?

"stage 0" membranous nephopathy can occur. Typically this seen early in recurrent MN in transplants. but I am very surprised by the EM discrepancy in this case. Can you clarify the clinical situation for the biopsy?

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Wide variety of morphologies in this case of crystalline light chain proximal tubulopathy: mottle lysosomes, crystals, and fibrils. #renalpath #nephsky #pathsky

One of the more subtle amyloid cases I have seen. Just a few deposits in 2 gloms by LM. Just enough congo red staining. Glad to catch it in the EM as well. #renalpath #nephsky #pathsky

Thank you. I am fortunate to have an excellent histology lab. The staining is mostly done on the grid (Uranyl acetate/ lead citrate). Osmium tetroxide is used in block preparation which also provides some contrast.

Some well formed "eye lashes" on these capillary loops in a case of AL-amyloidosis. Podocytes getting skewered by the spicules in the EM. #renalpath #pathsky #nephsky.

Classic example of Alport spectrum disease in a patient with X-linked Alport syndrome. Lesions of segmental glomerulosclerosis, numerous interstitial foam cells, and atypical GBMs with lamina densa splitting, subepithelial scalloping, and thinning. #renalpath #pathsky #nephsky

Some nice examples of severe tubulitis in this case of ACR 1B. Interestingly bx for new de novo DSA with with stable allograft function (~1 year post txp). No significant MVI. #renalpath #nephksy #pathsky

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Case of IgAN in the setting cirrhosis with prominent red blood cell casts with fairly focal crescents. Pt was biopsied for gross hematuria. #renalpath #pathsky #nephsky

Nice example of cryoGN in a Sjogren pt. Somewhat early kidney presentation with some active crescents without well-developed MPGN features. IgM-k dominant, less IgG/L (type II cryo). Cryo plugs in vessels. Great micro-tubles by EM. #renalpath #nephksy #pathsky

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very rare in my biopsy practice as well.

I don't know. This was a relatively recent biopsy, so I don't have any follow up at this point. The patient was not on hydroxycoloroquine or any other meds other than amlodipine.

Cases of Nail Patella have also been reported with MF as you note; there were no other ultrastructural features of this diagnosis in the biopsy.

Niemann-Pick disease type C with kidney involvement Niemann-Pick disease type C is a lysosomal storage disease characterized by defects in lipid trafficking, typically involving the liver, spleen, and c…

Yes, I consider a broad ddx in such cases and verify them descriptively as " myelin figures in podocytes" with recommendation for genetic testing. Fabry vs drug is the most likely issue; but I have seen rare cases such as N. Pick with similar findings (www.sciencedirect.com/science/arti...).

Few foamy appearing podocytes could be seen by LM. #renalpath #pathsky #nephsky

Older female pt with slowly progressive CKD, long h/o HTN. 0.5 g proteinuria. Biopsy with revealed a surprise with many podocytes demonstrating myelin figures. Main ddx includes Fabry versus drug effect (excluded in this case). pubmed.ncbi.nlm.nih.gov/35100945/. #renalpath #pathsky #nephsky

What is your leading diagnosis when seeing this interesting IgG staining pattern by IF? 

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Txp biopsy for DGF ~1 week post txp. Glomerular congestion, fibrin thrombi in arterioles, arterial mucoid intimal edema, and cortical necrosis c/w severe acute TMA. #renalpath #pthsky #nephsky

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